Age, Daily Stress Processes, and Allostatic Load: A Longitudinal Study

Protocol of the study: Multilevel community-based mental health intervention to address structural inequities and adverse disparate consequences of COVID-19 pandemic on Latinx Immigrants and African refugees

The NIMH-funded Multilevel Community-Based Mental Health Intervention to Address Structural Inequities and Adverse Disparate Consequences of COVID-19 Pandemic on Latinx Immigrants and African Refugees study aims to advance the science of multilevel interventions to reduce the disparate, adverse mental health, behavioral, and socioeconomic consequences of the COVID-19 pandemic that are a result of complex interactions between underlying structural inequities and barriers to health care. The study tests three nested levels of intervention: 1) an efficacious 4-month advocacy and mutual learning model (Refugee and Immigrant Well-being Project, RIWP); 2) engagement with community-based organizations (CBOs); and 3) structural policy changes enacted in response to the pandemic. This community-based participatory research (CBPR) study builds on long-standing collaboration with five CBOs. By including 240 Latinx immigrants and 60 African refugees recruited from CBO partners who are randomly assigned to treatment-as-usual CBO involvement or the RIWP intervention and a comparison group comprised of a random sample of 300 Latinx immigrants, this mixed methods longitudinal waitlist control group design study with seven time points over 36 months tests the effectiveness of the RIWP intervention and engagement with CBOs to reduce psychological distress, daily stressors, and economic precarity and increase protective factors (social support, access to resources, English proficiency, cultural connectedness). The study also tests the ability of the RIWP intervention and engagement with CBOs to increase access to the direct benefits of structural interventions. This paper reports on the theoretical basis, design, qualitative and quantitative analysis plan, and power for the study.

Are In-the-Moment Resilience Processes Predicted by Questionnaire-Based Measures of Resilience?

Research on resilience is a growing field, and resilience has been conceptualized and operationalized in multiple ways. The aim of this study was to compare the Brief Resilient Coping Scale (BRCS), a conventional measure of resilience, with within-person process indicators derived from experience sampling method (ESM). A sample of 177 teachers from southern Finland participated in the study, commencing with a startup session followed by an 8-day ESM period. Through twice-daily prompts, participants reported their immediate positive and negative affect as well as recent stressors encountered, such as workload and challenging social interactions. As expected, within-person variation in affect was predicted by stressors. However, contrary to expectations, individual differences in affective reactivity to stressors were not predicted by BRCS (βpositive affect [95% CI] = -.20, [-.51, .11]; βnegative affect = .33, [-.07, .69]). Item response theory analyses of the BRCS revealed problems with precision. The results call into question the validity of measuring resilience using single administrations of retrospective self-report questionnaires such as the BRCS.

Stress and Allostatic Load in Patients With Primary Open Angle Glaucoma

PRCIS

This study evaluated the allostatic load (AL) in primary open angle glaucoma (POAG) patients and reported that the AL score was significantly higher in glaucoma patients compared with age-matched controls.

PURPOSE

To evaluate the AL in patients with POAG.

METHODS

This case-control study comprised 50 POAG (glaucoma patients) and 50 age-matched controls without glaucoma (controls). AL was estimated based on 13 variables: systolic blood pressure (BP), diastolic BP, homocysteine, triglycerides, total cholesterol, high-density lipoprotein, low-density lipoprotein, body mass index, serum cortisol, glycosylated hemoglobin, albumin, creatinine clearance, and C-reactive protein. High-risk thresholds were determined based on biological cutoffs of each biomarker. One point was assigned for each biomarker reading above cutoff and were summated to obtain AL score; score ≥4 was considered high.

RESULTS

Mean age of glaucoma patients was 60.82±6.26 and 60.14±6.72 years in controls ( P =0.602). All components of AL score (except C-reactive protein) had higher values in glaucoma patients. There was a statistically significant difference in homocysteine ( P =0.001), total cholesterol ( P =0.037), high-density lipoprotein ( P =0.005), and glycosylated hemoglobin ( P =0.003). Mean AL score was 4.68±2.09 in glaucoma patients and 3.32±1.34 in controls ( P <0.001). There was significant association of high AL score with older age ( P =0.006), low socioeconomic status ( P =0.020), and glaucoma severity ( P =0.001). Negative correlation was seen between AL and retinal nerve fiber layer thickness (Right Eye: r =-0.37, P <0.001; Left Eye: r =-0.298, P <0.001) and visual field mean deviation (Right Eye: r =-0.469, P <0.001; Left Eye: r =-0.520, P <0.001).

CONCLUSIONS

Glaucoma patients exhibited allostatic overload indicating physiological dysregulation to chronic stress although additional research is required to establish causality. A holistic approach with lifestyle modifications to reduce chronic stress should be an integral part of managing glaucoma patients as it would serve both to possibly reduce or prevent disease progression and improve overall health outcomes.

Associations of Socioeconomic Factors and Unhealthy Lifestyles with Allostatic Load: A Meta-analysis

BACKGROUND

Allostatic load (AL) is a biological tool for objectively assessing chronic stress and has been discussed inconsistently for its correlation with socioeconomic factors and unhealthy lifestyles. Therefore, this meta-analysis was performed to explore the impact of socioeconomic factors and unhealthy lifestyles on AL.

METHOD

Different databases, including Web of Science, PubMed, EBSCOhost, Embase, CNKI, VIP, SinoMed, and Wanfang, were searched from inception to June 6, 2023. A total of 25 studies, reporting the correlations of seven socioeconomic factors and three unhealthy lifestyles with AL, were finally included. The pooled odds ratios (OR) and 95% confidence intervals (CIs) were examined using random-effect and fixed-effect models. Literature quality, heterogeneity, and publication bias were evaluated.

RESULTS

The meta-analysis showed a significantly increased risk of high AL in the older individuals as compared to the younger ones (OR = 1.05, 95% CI 1.04-1.06), in the individual with low education as compared to those with high education (OR = 1.25, 95% CI 1.05-1.48), and in the individuals with low physical activities as compared to those with high physical activities (OR = 1.44, 95% CI 1.26-1.64). This meta-analysis also showed a significantly decreased risk of high AL in the individuals with high income as compared to those with low income (OR = 0.77, 95% CI 0.71-0.83) and in women as compared to men (OR = 0.80, 95% CI 0.80-0.81).

CONCLUSION

This meta-analysis showed older people, men, and people having low physical activity, low income, and low education were more likely to have a high AL.

TRIAL REGISTRATION

This meta-analysis was registered on the PROSPERO database with trial registration number CRD42022326105. Instead of providing information at registration, we added an author (Tingyu Mu), who provided critical revisions to the paper in this meta-analysis.

Age Differences Among Different Sources of Stressor Related Negative Affect

We examine age differences in the relationship between negative affect (NA) and different indicators of daily stress (interpersonal, health, and financial stressors and perceived stress). Participants completed 56 days of daily diary surveys from Wave 1 of the Notre Dame Study of Health & Well-being. Multi-level modeling allowed us to assess the within-person relationships between daily stress and NA and the cross-level interactions between these daily relationships and cross-sectional age. Each type of stress additively related to daily NA. Older age related to an exacerbated relationship between daily interpersonal stressors and NA, but a weaker relationship between daily perceived stress and NA. Interventions focused on enhancing daily well-being can encourage older adults to ensure they do not have overpacked schedules in regards to social relationships, and encourage midlife and younger adults to engage in activities that disrupt the link between perceived stress and NA.

The allostatic load model: a framework to understand the cumulative multi-system impact of work-related psychosocial stress exposure among firefighters

Firefighting is recognised as a profession where health and well-being can be affected by a variety of occupational factors, such as physical, thermal, and chemical stressors. Along with the risks intuitively associated with the fire service, however, psychosocial stress has begun to attract attention as another variable deserving of consideration. Indeed, long-term exposure to work-related psychosocial stress has been linked with poor health outcomes in many workers; however, despite this association, very little has been done to examine how such stressors become biologically embedded in firefighters. To help facilitate research into how psychosocial stress can affect health-related outcomes in the fire service, we propose a framework centered on the notion of allostatic load. First, we reviewed the occupational characteristics that may generate psychosocial stress within firefighters before introducing allostatic load (that is, dysregulation across various physiological systems caused by the need to manage ongoing stressors). Next, we provided a summary of how allostatic load can be measured and touched on the framework's utility for studying the cumulative effects of work-related stress on firefighter health. After this, factors that may influence the steps leading from stress exposure to health outcomes were discussed; in particular, we commented upon how research in this area should consider specific non-modifiable (age, sex, and ethnicity) and modifiable (psychosocial resources and behavioural habits) factors. Finally, we presented methodological barriers and opportunities that may arise when using the allostatic load framework with this professional group. By introducing the framework, we hope to provide a tool that may be used by those interested in stress-health research in firefighters to build the evidence needed to inform primary prevention measures.

The interplay between sexual abuse and inflammation, oxidative stress, and DNA damage in drug-naïve panic disorder patients

Although accumulating evidence suggests an interplay between child abuse and inflammatory processes and the pathophysiology of mental disorders, few studies have investigated the cellular mechanisms related to this matter. Furthermore, no studies to date have evaluated cytokine, oxidative stress, and DNA damage levels in drug-naïve panic disorder (PD) patients and their possible association with childhood trauma. The aim of the present study was to determine the levels of the proinflammatory interleukin (IL)-1B, the oxidative stress marker TBARS, and  8-hydroxy-2' -deoxyguanosine (8-OHdG; representing DNA damage) in drug-naïve PD patients compared to controls. Furthermore, this investigation aimed to determine whether early-life trauma could predict peripheral levels of the previously mentioned markers in unmedicated PD patients. This work showed that drug-naïve PD patients presented elevated levels of TBARS and IL-1B but not 8-OHdG compared to healthy controls. In addition, sexual abuse during childhood was associated with increased levels of IL-1B in PD patients. Our findings suggest that the microglial NLRP3 inflammasome complex might be activated in drug-naïve PD patients. This study is the first to associated sexual abuse with increased levels of IL-1B in drug-naïve PD patients and to demonstrate that this population presents high concentrations of oxidative stress and inflammation markers but not DNA damage markers when compared to healthy controls. Independent replication of these findings would support further clinical trials of inflammasome inhibitory drugs in PD patients, which could lead to effective novel treatments for people with PD and contribute to elucidating pathophysiological differences depending on trauma exposure in the immune disturbances accompanying PD.

Comparing Predictors and Outcomes of Higher Allostatic Load across Zoo-Housed African Great Apes

Stressors over the lifespan can contribute to physiological dysregulation, or allostatic load. Allostatic load has been studied in humans using allostatic load indices (ALIs) for over 25 years, but the same methods are rarely applied to other species. We constructed an ALI for zoo-housed western lowland gorillas, chimpanzees, and bonobos and tested potential predictors of and health outcomes associated with allostatic load. Allostatic load scores ranged from 0–6 for gorillas and chimpanzees and 0–7 for bonobos. Age was significantly associated with allostatic load in gorillas and chimpanzees but not bonobos. Cumulative stressful events were positively associated with allostatic load in chimpanzees. Wild-caught gorillas had higher allostatic load than zoo-born conspecifics, but rearing differences between zoo-born animals were not significant for any species. Age may affect associations of allostatic load with stressful events and birthplace as results change when it is included as a covariate. Allostatic load was not retained in best-fit models for risk of all-cause morbidity, cardiac disease, or mortality risk. Some analyses herein were limited by the use of retrospective data, such as reason for sample collection and length of records provided for individual animals. Nevertheless, these data indicate additional research is needed to optimize ALIs for non-human primates.

Aging, frailty, and design of built environments

Before developing agriculture, herding or metallurgy, humans occupied most of the world. Multiple socioculturally-based responses supported their migration, including building shelters and constructing niches to limit environmental stressors. Sheltered settings provided social support and security during stressful times, along with opportunities for injured, aging, and frail members to survive. Modern built environments are designed for similar purposes, to support human growth, development, reproduction, and maintenance. However, extended survival in modern settings has costs. With age, muscle (sarcopenia) and bone loss (osteopenia, osteoporosis), along with somatic, physiological, and sensory dysfunction, reduce our physical capabilities, increase our frailty, and impede our abilities to interface with built and natural environments and manufactured artifacts. Thereby, increasing our dependence on built environments to maintain autonomy and quality of life.

What follows is a conceptual review of how frailty may limit seniors within modern built environments. It suggests age-related frailty among seniors provides specific data for those designing environments for accessibility to all users. It is based in human ecological theory, and physiological and gerontological research showing senescent alterations, including losses of muscle, bone, and sensory perceptions, produce a frail phenotype with increasing age limiting our mobility, activity, use of space, and physical abilities. As an individual phenotype, frailty leads to age-related physical and performance declines. As a physiological assessment, frailty indices amalgamate individual measures of functional abilities into a single score. Such frailty indices increase with age and differ betwixt individuals and across groups. To design built environments that improve access, usability, and safety for aging and frail citizens, today’s seniors provide living samples and evidence for determining their future abilities, limitations, and design needs. Designing built environments to accommodate and improve the quality of human-environment interactions for frail seniors will improve usability and accessibility for most user groups.

The Relational Wear and Tear of Everyday Racism Among African American Couples

The wear and tear of adapting to chronic stressors such as racism and discrimination can have detrimental effects on mental and physical health. Here, we investigated the wider implications of everyday racism for relationship quality in an adult sample of 98 heterosexual African American couples. Participants reported on their experiences of racial discrimination and positive and negative affect for 21 consecutive evenings. Using dyadic analyses, we found that independently of age, gender, marital status, income, racial-discrimination frequency, neuroticism, and mean levels of affect, participants' relationship quality was inversely associated with their partner's negative affective reactivity to racial discrimination. Associations did not vary by gender, suggesting that the effects of affective reactivity were similar for men and women. These findings highlight the importance of a dyadic approach and call for further research examining the role of everyday racism as a key source of stress in the lives of African American couples.

Advancing the Study of Resilience to Daily Stressors

Historically, studies of childhood and adult resilience have typically focused on adaptation to chronic life adversities, such as poverty and maltreatment, or isolated and potentially traumatic events, such as bereavement and serious illness. Here, we present a complementary view and suggest that stressors experienced in daily life may also forecast individual health and well-being. We argue that daily process approaches that incorporate intensive sampling of individuals in natural settings can provide powerful insights into unfolding adaptational processes. In making this argument, we review studies that link intraindividual dynamics with diverse health-related phenomena. Findings from this research provide support for a multiple-levels-analysis perspective that embraces greater unity in pivotal resilience constructs invoked across childhood and adult literatures. Drawing on insights and principles derived from life-span theory, we conclude by outlining promising directions for future work and considering their broader implications for the field of resilience.

Effects of a workplace intervention on daily stressor reactivity

Heightened affective and physical reactions to daily stressful events predict poor long-term physical and mental health outcomes. It is unknown, however, if an experimental manipulation designed to increase interpersonal resources at work can reduce associations between daily stressors and physical and affective well-being. The present study tests the effects of a workplace intervention designed to increase supervisor support for family and personal life and schedule control on employees' affective and physical reactivity to daily stressors in different domains (i.e., work, home, interpersonal, and noninterpersonal stressors). Participants were 102 employed parents with adolescent children from an information technology (IT) division of a large U.S. firm who participated in the Work, Family, and Heath Study. Participants provided 8-day daily diary data at baseline and again at a 12-month follow-up after the implementation of a workplace intervention. Multilevel models revealed that the intervention significantly reduced employees' negative affect reactivity to work stressors and noninterpersonal stressors, compared to the usual practice condition. Negative reactivity did not decrease for nonwork or interpersonal stressors. The intervention also did not significantly reduce positive affect reactivity or physical symptom reactivity to any stressor type. Results demonstrate that making positive changes in work environments, including increasing supervisor support and flexible scheduling, may promote employee health and well-being through better affective responses to common daily stressors at work. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Does allostatic load predict incidental coronary events differently among sexes?

Background

One measure to quantify the degree of dysregulation is allostatic load (AL). Typically, AL incorporates information on diverse biomarkers and is associated with health outcomes such as cardiovascular diseases or the incidence of coronary events (C-E).

Aims

This study investigates the predictive performance of different AL scoring methods on the incidence of coronary events (C-E). This study also elaborates sex differences in the baseline risks of C-E and the AL associated risks of C-E.

Design

Longitudinal data analysis of the Heinz Nixdorf Recall Study (Risk Factors, Evaluation of Coronary Calcification, and Lifestyle) of 4327 participants free of C-E at study baseline aged 45–75. The data contains over 13 biomarkers measuring AL.

Methods

After conducting multiple imputations on missing values on AL for 826 participants, the analysis sample consisted of N = 4327 participants. We applied the two most commonly used methods of AL scoring AL (count-based and Z-score) and a recently developed logistic regression weighting method (LRM) approach. Cox regression was used to predict the incidence of C-E for each AL score. Results were estimated without (M0) and with (M1) covariate adjustment, and in a final model (M2), with an interaction between AL and sex.

Results

We found no violation of the proportional hazard assumption and significant differences in the survival curves between the sexes for C-E (Log-rank test: prob. > Chi² = 0.000). In M0, all AL-scoring methods predicted C-E significantly, with the LRM based AL-score having the best performance (hazard ratio = 3.133; CI: [2.630, 3.732]; Somer's D = 0.717). After covariate inclusion, differences between the scoring methods levelled, though the count-based method and LRM performed better than the Z-scoring method. The interaction analysis in M2 showed a significant multiplicative interaction for the count-based method (1.254; [1.066, 1.475]) and for the LRM (1.746; [1.132, 2.692]). The additive relative excess risk due to interaction (RERI) measure was negative for the count-based method (RERI = −1.967; [-3.778; −0.156]) and the LRM (RERI = −1.909 [-3.910; 0.091]), indicating subadditivity.

Conclusion

AL scores are suitable for predicting C-E. Differences between the AL-scoring algorithms were only present after including interactions. We value the count-based method as suitable for clinical practice since its calculation is relatively simple, and performance was among the best. Interaction analysis revealed that despite strong sex differences in baseline C-E, the effect of AL is more pronounced for females at high levels of AL; thus, females could benefit more from a potential intervention on AL. We suggest further investigation of sex differences concerning the mediation by physiological and psychological intermediates.

Allostatic load and mental health during COVID-19: The moderating role of neuroticism

Background

During the COVID-19 pandemic increased risk of poor mental health has been evident across different cultures and contexts. This study aims to examine whether allostatic load (AL) prior to the pandemic was predictive of poor mental health during the pandemic, and if any associations were moderated by neuroticism.

Methods

Data were extracted from Waves 2 (2011, allostatic load), 3 (2012, neuroticism), and the COVID-19 study (April 2020) of the Understanding Society database in the UK; data were available for 956 participants.

Results

Mental health increased from 2012- to during the pandemic. Neuroticism and AL were positively associated with poorer mental health during COVID-19, such that those who had scored higher on neuroticism and had higher AL prior to the pandemic reported poorer mental health during the pandemic. Neuroticism was also a significant moderator; the effect of AL on mental health during the pandemic was exacerbated in those with high and moderate levels of neuroticism but not lower. Moreover, this was driven by the immune-related indices of AL. This withstood adjustment for age, gender, employment status and prior mental health. These findings are discussed in relation to the pathophysiological mechanisms of mental health.

Personality Traits Predict Long-Term Physical Health via Affect Reactivity to Daily Stressors

Researchers hypothesize that how people react to daily stressful events partly explains the relationship between personality and health, yet no study has examined longitudinal associations between these factors. The current study focused on the role of negative affect reactivity to daily stressful events as a mediating pathway between personality and physical health outcomes using three waves of data spanning 20 years from a nationwide probability sample of 1,176 adults. Results indicated that negative affect reactivity partially mediated personality and physical health. Wave 1 neuroticism was associated with greater negative affect reactivity at Wave 2, which predicted the development of chronic conditions and functional limitations at Wave 3. Higher conscientiousness at Wave 1 was associated with less negative affect reactivity at Wave 2, which predicted better physical health at Wave 3. These findings highlight the usefulness of using a daily-stress framework for understanding how personality impacts health over time, which has important implications for stress management and disease prevention.

Aging and Allostasis: Using Bayesian Network Analytics to Explore and Evaluate Allostatic Markers in the Context of Aging

Allostatic load reflects the cumulative strain on organic functions that may gradually evolve into overt disease. Our aim was to evaluate the allostatic parameters in the context of aging, and identify the parameters that may be suitable for an allostatic load index for elderly people (>60 years). From previously published studies, 11 allostatic (bio)markers could be identified that sustain sufficient variability with aging to capture meaningful changes in health status. Based on reported statistics (prevalence of a biomarker and its associated outcome, and/or an odds/risk ratio relating these two), seven of these could be adopted in a Bayesian Belief Network (BBN), providing the probability of “disturbed” allostasis in any given elder. Additional statistical analyses showed that changes in IL-6 and BMI contributed the most to a “disturbed” allostasis, indicating their prognostic potential in relation to deteriorating health in otherwise generally healthy elderly. In this way, and despite the natural decline in variance that irrevocably alters the prognostic relevance of most allostatic (bio)markers with aging, it appeared possible to outline an allostatic load index specifically for the elderly. The allostatic parameters here identified might consequently be considered a useful basis for future quantitative modelling in the context of (healthy) aging.

Charting adult development through (historically changing) daily stress processes

This article views adult development through the lens of daily life experiences and recent historical changes in these experiences. In particular, it examines whether theories that postulate general linear increases in well-being throughout adulthood still hold during times of less prosperity and more uncertainty. Descriptive analyses of the National Study of Daily Experiences chart show how stress in the daily lives of Americans may have changed from the 1990s (N = 1,499) to the 2010s (N = 782). Results revealed that adults in the 2010s reported experiencing stressors on 2% more days than in the 1990s, which translates to an additional week of stressors across a year. Participants in the 2010s also reported that stressors were more severe and posed more risks to future plans and finances and that they experienced more distress. These historical changes were particularly pronounced among middle-aged adults (e.g., proportion of stressor days increased by 19%, and perceived risks to finances and to future plans rose by 61% and 52%, respectively). As a consequence, age-related linear increases in well-being observed from young adulthood to midlife in the 1990s were no longer observed in the 2010s. If further studies continue to replicate our findings, traditional theories of adult well-being that were developed and empirically tested during times of relative economic prosperity may need to be reevaluated in light of the changes in middle adulthood currently observed in this historic period. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Minimally-invasive methods for examining biological changes in response to chronic stress: A scoping review

BACKGROUND

Nurse researchers are increasingly interested in incorporating biological indicators related to chronic stress, or repeated or constant exposure to psychological stressors. Minimally invasive collection methods may improve access to vulnerable populations.

OBJECTIVE

To map biological indicators measured through minimally invasive methods investigating biological changes in response to chronic stress.

DESIGN, DATA SOURCES, AND METHODS

The paper seeks to answer two questions: What are the characteristics of the minimally-invasive methods used to measure the biological correlates of chronic stress? What are the limitations regarding the use of the minimally-invasive methods and/or biological indicators identified above? Authors completed a scoping review following guidelines from the Joanna Briggs Institute Manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews. A literature search was completed in PubMed, PsycINFO, and Scopus. 2518 articles were screened and 145 studies were included. Data were extracted using a standardized extraction tool, compiled, and coded.

RESULTS

Studies included minimally-invasive methods to measure the hypothalamic-adrenal-pituitary axis (N = 173), immune and inflammatory markers (N = 118), and adult neurogenesis (N = 6). Cortisol was most frequently measured (N = 136), usually in saliva (N = 86). Studies included a variety of limitations for the methods and indicators, including concerns about timing and accuracy of collection, frequency of sampling, and controlling for acute stressors.

CONCLUSIONS

Nurse researchers have access to many minimally-invasive methods to measure altered biological processes related to chronic stress. A gap identified by this review is the paucity of minimally-invasive methods for investigating neurogenesis; the measurement of brain derived neurotrophic factor in plasma is a distal proxy and further research is needed to test the response of peripheral levels to psychosocial stress interventions. Additionally, while this scoping review allows nurse researchers to consider possible biological indicators to include in their research, future research is still needed on some of the basic premises of stress research, including agreement on the conceptualization of chronic stress.

Biopsychosocial approach to understanding resilience: Stress habituation and where to intervene

BACKGROUND

Resilience in the face of adversity is a human experience that leads to better health, both mentally and physically. We briefly review its historical origins rooted in ecological biology and its adoption into health care. Resilience is the common response to adversity or potential traumatic events. Individual differences in emotion regulation and coping skills as well as social capital and one's physical environment influence a person's ability to achieve resilience.

PROPOSED MECHANISM

One potential biopsychosocial measure of resilience includes stress habituation to repeated stress as demonstrated in the laboratory, possibly providing a tool to observe mastery of resilience training in the clinic. Evidence-based interventions at the individual and small group level (eg, family, classroom) have successfully shown development of resilient behaviours and improved mental and physical health outcomes. However, the role of social context and public policy clearly influence an individual's ability to be resilient.

CONCLUSIONS

Despite the current limited evidence of the effectiveness of resilience building interventions, clinicians, researchers, and other health care professions have an obligation to become advocates for laws and policies that support the most vulnerable, and least resilient, in our society to attain resilience for their health. This salutary effect will enable them to become socially as well as economically productive members of the community at large. It is not possible to remove stress or adversity from life, but we can influence the development of regulatory flexibility and decrease the sociocultural factors linked to the nonresilient experience, thus mitigating adversity's long-term effects on health.